Jean-Yves Sichel

Nonsurgical Management of Parapharyngeal Space Infections: A Prospective Study

Objective/Hypothesis Parapharyngeal infections, which can potentially cause life‐threatening complications, may, in certain cases, be treated conservatively with no need for surgical drainage. A review of the literature reveals that the most recommended treatment of parapharyngeal infection is surgical drainage combined with intravenous antibiotic therapy. Several retrospective reports recommend conservative treatment with no surgical drainage.

Computed Tomography Diagnosis of Esophageal Bone Impaction: A Prospective Study:

A prospective study was performed on 45 patients for an assessment of the use of computed tomography (CT) in the management of a suspected esophageal fish bone or chicken bone. All patients had negative findings on laryngoscopy; therefore, pharyngeal and hypopharyngeal foreign bodies were excluded from further consideration. The patients underwent radiographic examination with plain films and a cervical CT scan without contrast material. Patients with positive findings were taken to the operating room, where they underwent rigid esophagoscopy under general anesthesia, while those with negative findings remained for observation for 24 hours. Thirty CT scans were positive for an esophageal foreign body, and in all cases but 1, a foreign body was found during the operation. Fourteen of 15 patients with normal CT scan findings managed well with no further intervention. One patient with persistent complaints underwent esophagoscopy, but no foreign body was found. Our conclusion is therefore that CT is a simple and reliable method for diagnosing esophageal bone impaction and may reduce the rate of unnecessary esophagoscopies.

Vestibular and cochlear ototoxicity of topical antiseptics assessed by evoked potentials.

Objectives/Hypothesis To evaluate and compare the effect of chlorhexidine gluconate, povidone‐iodine, and alcohol—three antiseptics used before ear surgery—on the function of the vestibular and cochlear parts of the sand rats inner ear. The assessment of damage is based on the recording of vestibular evoked potentials (VsEPs) and auditory brainstem response (ABR).

Redefining Parapharyngeal Space Infections

Objectives: Our intent was to review the clinical signs, computed tomography (CT) scans, treatment, and outcome of parapharyngeal space infections (PPIs), and to define 2 types of infections of the parapharyngeal space (PPS) according to the location of the infectious process. Methods: We performed a retrospective analysis of patients hospitalized in a tertiary university hospital with a diagnosis of PPI, abscess, or deep neck abscess between 1988 and 2004. Files and CT scans were reviewed after classification into 2 groups: 1) infection located in the posterior part of the PPS (PostPPI); and 2) infection located in the anterior part of the PPS(AntPPI). Results: Twenty-two patients had a PostPPI; their ages ranged from 10 months to 24 years. Five patients underwent surgical drainage, and 17 others were treated solely with intravenous antibiotic therapy. No pus was found during surgery in 2 patients. The average time of hospitalization was 10 days. Only 1 complication (aspiration pneumonia) was observed. Seven patients had an AntPPI; their ages ranged from 1.5 years to 65 years. All patients underwent surgical drainage, and pus was detected in all cases. The average time of hospitalization was 35 days. Complications (septic shock, respiratory arrest, mediastinitis, pleural empyema, pericarditis) were observed in 4 patients. Conclusions: The term “parapharyngeal abscess” was assigned long before the CT scan era, and was based on physical examination and plain film radiology. In essence, the entity PPS “abscess” or “infection” is composed of 2 different disorders. Infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and with no extension into other cervical spaces except the adjacent retropharyngeal space may be termed posterior parapharyngeal infection or parapharyngeal lymphadenitis. This is a relatively benign condition, and nonsurgical treatment should be considered. Infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. Urgent surgical drainage is therefore mandatory.

Parapharyngeal abscess in children: the role of CT for diagnosis and treatment

Parapharyngeal abscess (PPA) in children is an uncommon deep neck space infection. Computerized tomography (CT) is an important diagnostic aid. However, CT scan is not specific in differentiating an abscess from cellulitis or inflammatory edema. A retrospective review of eight children with a CT diagnosis of PPA was undertaken. In three patients an abscess was surgically confirmed. In two patients surgical exploration did not reveal an abscess and in three the infection resolved with intravenous antibiotic therapy only. Although CT is a useful diagnostic tool for PPA, surgical intervention should be based mainly on the clinical status of the patient and the non-responsiveness to i.v. antibiotic therapy.

Management of Congenital Laryngeal Malformations

Congenital malformations of the larynx are relatively rare but may be life-threatening. The most common causes include laryngomalacia, vocal cord paralysis, and subglottic stenosis. The last 20 years has seen major advances in the field of surgical correction of such anomalies also serving to reduce the number of tracheotomies in children and the inherent dangers they pose. Success rates for the most popular surgical procedures have been favorable. These include supraglottoplasty for cases of severe laryngomalacia, in which relief of respiratory symptoms has been shown to occur in excess of 80% of cases. Complication rate is low, although postoperative death has been reported. Failure usually occurs in patients with concomitant airway abnormalities including pharyngomalacia. Vocal cord lateralization for vocal cord paralysis with airway compromise is achieved by means of arytenoidopexy or arytenoidectomy, using the lateral approach. Arytenoidectomy also can be performed using laryngofissure or endoscopic laser excision. Subglottic stenosis is the 3rd most common congenital anomaly. Anterior or multiple cricoid splitting with cartilage graft interpositioning is usually performed. The success rates for these procedures has been shown to be approximately 90%.

Vestibular end-organ impairment in an animal model of type 2 diabetes mellitus.

Objectives/Hypothesis To define and assess the functional impairment of the vestibular part of the inner ear in a diabetic state, using a direct and objective test for evaluating the vestibular end‐organ and an animal model for diet‐induced type 2 diabetes mellitus.

The Pathway Enabling External Sounds to Reach and Excite the Fetal Inner Ear

The human fetus in utero is able to respond to sounds in the amniotic fluid enveloping the fetus after about 20 weeks gestation. The pathway by which sound reaches and activates the fetal inner ear is not entirely known. It has been suggested that in this total fluid environment, the tympanic membrane and the round window membrane become ‘transparent’ to the sound field, enabling the sounds to reach the inner ear directly through the tympanic membrane and the round window membrane. It is also possible that sounds reach the inner ear by means of tympanic membrane – ossicular chain – stapes footplate conduction (as in normal air conduction). There is also evidence that sounds reach the fetal inner ear by bone conduction. Several animal and human models of the fetus in utero were studied here in order to investigate the pathway enabling sounds to reach and activate the fetal inner ear. This included studying the auditory responses to sound stimuli of animals and humans under water. It was clearly shown in all the models that the dominant mechanism was bone conduction, with little if any contribution from the external and middle ears. Based on earlier experiments on the mechanism and pathway of bone conduction, the results of this study lead to the suggestion that the skull bone vibrations induced by the sound field in the amniotic fluid enveloping the fetus probably give rise to a sound field within the fetal cranial cavity (brain and CSF) which reaches the fetal inner ear through fluid communication channels connecting the cranial cavity and the inner ear.

Clinical update on type II first branchial cleft cysts

Objective: To describe clinical and radiological signs of type II first branchial cleft cyst in order to facilitate diagnosis. Method: Report of three cases of first branchial cleft cyst type II (one of them in association with ipsilateral agenesis of the parotid gland) and review of the literature. Results: Two clinical signs are described: the location of the sinus opening in the neck, which is situated in a triangle limited by the external auditory canal above, the mental region anteriorly, and the hyoid bone inferiorly, and the presence in some cases of a myringeal web that runs from the floor of the external auditory canal to the umbo. In addition, imaging with computed tomography and magnetic resonance of the parotid area may be helpful in confirming the diagnosis. Laryngoscope, 108:1524–1527, 1998

Acute mastoiditis in children: is computed tomography always necessary?

Objectives Acute mastoiditis (AM) is the most common intratemporal complication of acute otitis media in children. In the past decade, reports have indicated a rise in the incidence of AM in the pediatric population. A parallel rise in the use of computed tomography (CT) imaging has occurred. The rise in the use of CT scanning in the pediatric population, entraining with it a rise in pediatric brain irradiation, has led us to question the necessity of using CT for pediatric patients with AM. Methods We reviewed the medical files of pediatric patients who had AM in the years 2005 through 2007. Results Fifty patients were identified. The gender distribution was equal, and the ages ranged from 4 months to 12 years. Of the 46 patients who were admitted to our institution “de novo,” only 2 underwent CT scanning on admission, and 4 other patients had CT performed during hospitalization. The majority of patients (92%) with AM did not have a CT scan performed and were treated conservatively with no complications. Conclusions In most pediatric patients, CT does not seem to be indispensable in the diagnosis of AM. Conservative therapy and close follow-up seem to suffice for most.